New integrated care models in England associated with small reduction in hospital admissions in longer-term: A difference-in-differences analysis

Abstract

Closer integration of health and social care services has become a cornerstone policy in many developed countries, but there is still debate over what population and service level is best to target. In England, the 2019 Long Term Plan for the National Health Service included a commitment to spread the integration prototypes piloted under the Vanguard `New Care Models' programme. The programme, running from 2015 to 2018, was one of the largest pilots in English history, covering around 9 % of the population. It was largely intended to design prototypes aimed at reducing hospital utilisation by moving specialist care out of hospital into the community and by fostering coordination of health, care and rehabilitation services for (i) the whole population ('population-based sites'), or (ii) care home residents ('care home sites'). We evaluate and compare the efficacy of the population-based and care home site integrated care models in reducing hospital utilisation. We use area-level monthly counts of emergency admissions and bed-days obtained from administrative data using a quasi-experimental difference-in-differences design. We found that Vanguard sites had higher hospital utilisation than non-participants in the pre-intervention period. In the post-intervention period, there is clear evidence of a substantial increase in emergency admissions among non-Vanguard sites. The Vanguard integrated care programme slowed the rise in emergency admissions, especially in care home sites and in the third and final year. There was no significant reduction in bed-days. In conclusion, integrated care policies should not be relied upon to make large reductions in hospital activity in the short-run, especially for population-based models.

Keywords: Care homes; England; Hospital admissions; Integrated care; New Care Models; Vanguard.

Fig. 1

Emergency admission and total bed-days rates in the Vanguards and non-Vanguard sites, before and after the Vanguard introduction. Notes: the lines represent locally weighted regressions (bandwidth = 0.2) of the raw monthly outcomes averaged by groups (scatter points) on time (pre- post-intervention). The grey area identifies the period between January 2015 (when the NHS invited individual organisations and partnerships to apply to become Vanguard) and March 2015 (when population-based and care home sites were selected).

Fig. 2

Difference-in-differences estimates of changes in emergency admissions and total bed-days rates attributable to the Vanguard population-based and care home models, by age groups. Notes: Bars represent the magnitude of the estimated ${\beta }_j$ parameters (horizontal lines identify 95 % associated confidence intervals) of site and time fixed-effect specifications based on the balanced sample (223 sites: 31 population-based sites, 6 care home sites and 186 control sites) that use the full 24-months before implementation (see sub-Section 2.2 for details) by age-groups. See Supplementary Appendix 5 for age-group specific time trends on outcomes and pre-intervention trend parallelism tests. ${\beta }_j$ parameters are provided in Supplementary Appendix 6